Provider Demographics
NPI:1922093319
Name:CLARK-MCGILL, DIANA KATHERINE (PA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:KATHERINE
Last Name:CLARK-MCGILL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 KINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-3040
Mailing Address - Country:US
Mailing Address - Phone:832-548-4420
Mailing Address - Fax:
Practice Address - Street 1:1450 KINGWOOD DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-3040
Practice Address - Country:US
Practice Address - Phone:832-548-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00395363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89N545OtherBLUE CROSS BLUE SHIELD
00889NMedicare PIN
R59529Medicare UPIN
8661KOMedicare ID - Type Unspecified